Upper GI Hemorrhage (UGIH)

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UGIB is bleeding derived from a source proximal to the Ligament of Treitz.

Photo by AJC1

Acute Upper G.I. Bleeding

Haematemesis
Melaena
Haematochezia

Haematemesis

The vomiting of blood.
It indicates that the bleeding is from a cause proximal to the (LOT).
The colour of the vomited blood is dependent on the concentration of HCL and its admixture with the blood .If the vomiting occurs soon after the UGIB , then haematemesis will be bright red in colour. IF there is a time lag then haematemesis will be dark red brown or black.

Melaena

The passage of black and tarry stools.
Usually due to UGIH.
It results from more then 60-100 ml of blood with moderate transit time.
Can be a result of LGIH if the GI transit time was sufficiently prolonged to about 8hrs.

Haematochezia

The passage of fresh blood per rectum due to bleeding from the lower GIT.
Rarely due to UGIB. Requires more than 1000ml.

GASTROINTESTINAL BLEEDING

Hematemesis
Melena
Hematochezia
Occult bleeding

Summary

Vomiting of blood
Bright red or dark
Proximal to the ligament of Treitz
Differentiate from hemoptysis, bleeding from mouth & pharynx
80-95% cases – Mucosal abnormalities, Varices, Spontaneous resolution

Causes of UGIH

Esophageal Varices
Duodenal ulcer
Gastric ulcer
Gastritis
Other rare causes are:

Mallory-Weiss tear.
Boerhaave syndrome.
Vascular Ectasia
Aortoenteric fistula.
Neoplasm
Portal hypertensive gastropathy.
Hemobilia.

CLINICAL PRESENTATION

Clinical manifestations of GI bleeding depends upon extent & rate
Postural hypotension suggests acute hemorrhage & intravascular volume depletion
Fatigue & exertional dyspnea typical symptoms with slow, chronic blood loss

Symptoms and Signs

Hematemesis – 40-50%
Melena – 70-80%
Hematochezia – 15-20%
Syncope – 14.4%
Presyncope – 43.2%
Dyspepsia – 18%
Epigastric pain – 41%
Heartburn – 21%
Diffuse abdominal pain – 10%
Dysphagia – 5%
Weight loss – 12%
Jaundice – 5.2%

Clinical Features

History

Differentiate hematemesis from hemoptysis

Amount of blood loss (drops, tablespoonful, clots)

Recently ingested foods (food colors, beets, drugs)

Source of bleed (upper GIT, nose, mouth pharynx)

Prolonged, forceful vomiting (Mallory-Weiss)

Abdominal pain & vomiting (esophagitis, gastritis)

Cracked nipples, Jaundice & Liver disease

Umbilical vein catheterization (portal vein thrombosis)

Familial bleeding diathesis

PHYSICAL

Orthostatic changes in pulse & BP
Cardiopulmonary
Skin
Examine oral cavity & nasopharynx
Lymph nodes
Abdomen
Digital rectal

Physical signs

Petechiae, Ecchymosis
Icterus, Palmar erythema, Spider angioma
Hepatosplenomegaly, Ascites
Active nasopharyngeal bleed
Occult blood in stools

Approach to the patient

GOAL — Determine the cause & treat

Phase – 1 Differentiate (blood, food color, Beets etc)

Phase – 2 Assess severity (Hematocrit, Capillary refilling, Vital signs)

Phase – 3 Determine the site ( Epistaxis simulates Upper G I bleed)

Imaging, Endoscopy

Clinical Approach

Confirm bleeding
Assess Severity
Resuscitate
Medical Intervention
Liaison with surgical/ ITC Team
Diagnosis of site
Surgical hand over

Hints for Screening

Make sure – vomited material: is it really blood ?

NG aspirate –ve for blood doesn’t rule out ‘UGIB’

Competent pylorus may mask a duodenal bleed

Bright red blood – active bleed

Dark ‘Coffee grounds’ – denatured by gastric acid

Rapid bleed – a medical emergency

Slower bleed – anemia, occult blood in stools, melena

Hypotension – may not be seen even in a large bleed

Initial Hb – values may be unreliable

Acute U.G.I. Bleeding

Clinical approach:

–1. if small amount, no immediate Tx, because CVS can compensate –

–2. 85% stop bleeding during 48 hrs –

–3. Criteria for low risk

Age less then 60 years
Coffee ground without malena
Alcohol induced
Hemodynamically normal

4. Criteria for Hospitalization

–recent (24 hrs),
–age (60 +)
–Continuing visible blood loss.
–Hemetemsis with malena
–Cardio-respiratory disease
–Signs of chronic liver disease
–Shock

P>100,BP<100
Poor peripheral circulation
JVP<1cm (from sternal angle when Patient is flat)

Immediate management:

** Emergency management:

History.

(Dyspeptic symptoms, Vomiting preceding blood, Alcohol, Drugs, Previous episode of bleeding, History of jaundice, peptic ulcer, surgery )

Monitor: pulse & BP /30 min
Blood sample: haemoglobin, urea electrolytes, grouping & cross-matching
I.v. access

**Shock management:

ABC
Airway: endotracheal tube, oropharyngeal airway.
*Give oxygen
Breathing: support respiratory function
* Monitor: resp. rate, blood gases, chest radiograph
– Circulation: expand circulating volume: blood, colloids, crystalloids support CVS function: vasodilators
* Monitor: skin color, peripheral temp., urine flow, BP, ECG

Blood transfusion in case of:

1) shock

2) haemoglobin <10 g/dl

Urgent endoscopy
Surgery when recommended

Rationale for Endoscopy

To identify the source of bleeding

To determine the risk of re-bleeding

To render endoscopic therapy

Band ligation
Injection sclerotherapy
Cautery
Heater probe
Endoclip

General Investigations:

1. Hb, PCV

2. CBC (WBC … etc)

3. Bld glucose

4. Platelets, coagulation

5. Urea, creatinine, electrolytes

6. Liver biochem.

7. Acid-base state

8. Imaging: chest & abd. radiography, US, CT

Laboratory Aids

1. Bleeding scans – Inconclusive Endoscopy

Technitium sulfur colloid (detects rapid bleed)

Tagged RBCs (for small bleeds)

2. Angiography

General management:

–Drug therapy

1. H2 – receptor antagonists

2. proton pump inhibitors

3. octreotide

4. Vasopressin/Terlipressin

Factors in reassessment

1. age: 60 + indicates greater mortality

2. recurrent hemorrhage: +++ mortality

3. re-bleeding: mostly within the 1st 48 hrs

Further Evaluation

Re-bleeding Signs:

–Rise in pulse

–Decreased urinary output

–General condition deterioration

–Continued bleeding after 6-8 units of blood

–Spurting vessel at endoscopy

Treatment of Uncontrolled Bleeding

Sengastaken– Blakemore tube
TIPSS
Surgical shunts

Prognosis

Overall mortality =8-12%

can be reduced to 6-9%